Authorization for Disclosure of Protected Health Information (PHI)

(Patient Permission to Release Information in the Medical Record)

Please correct the errors described below.

Release Information From:

Release Information To:

• Dr.Otha Myles & Associates, LLC has my permission to use or give out certain information in my medical record. The information the they may give out is check below.

• I also understand the PHI (protected health information) may include information protected under Federal and State Law (such as information about alcohol, drug abuse, mental health, HIV, and/or AIDS treatment.

Expiration of the Authorization: I understand that I may revoke this authorization at any time by sending a written notice to Dr. Myles & Associates, LLC at the address noted below. I understand that the revocation will not apply to any PHI that has already been released in association with this authorization.

I have read and understood this Authorization and my questions have been answered. I certify that I am the Patient listed above or a person with permission to act on Patient's behalf. I will not hold Dr. Myles & Associates, LLC its officers, trustees, employees, agents, or contractors responsible for anything that may happen from the use or release of my PHI.

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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